Snow and colleagues (1) provided clinical guidelines for the management of migraine by primary care physicians. Although these guidelines generally follow those published by the U.S. Headache Consortium (2), several issues relating to their advice may result in suboptimal care in clinical practice.

All recently published evidence-based guidelines for migraine management, including those of the U.S. Headache Consortium (2), the U.S. Primary Care Network (3), and the U.K. Migraine in Primary Care Advisors (4), provide evidence for and recommend a strategy of individualized care for migraine. The therapy is chosen on the basis of the historic pattern of attack characteristics and the severity of symptoms. Patients with consistent patterns of mild to moderate attacks may be effectively treated with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) but in all likelihood take such drugs without the aid of a medical provider. Patterns of migraine attacks that consistently become moderate to severe frequently do cause patients to seek medical attention, and almost inevitably there is a history of failed intervention with aspirin and over-the-counter NSAIDs. These attacks often require migraine-specific therapies, such as triptans or dihydroergotamine.